Barnet, Robert J.

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The Linacre QuarterlyVolume 53 | Number 4 Article 1511-1-1986[Book Review of ] Ethical Issues in Family Medicine,by Ronald J. Christie and C. Barry HoffmasterRobert J. BarnetFollow this and additional works at: http://epublications.marquette.edu/lnqPart of the Ethics and Political Philosophy Commons, and the Medicine and Health SciencesCommonsRecommended CitationBarnet, Robert J. (1986) "[Book Review of] Ethical Issues in Family Medicine, by Ronald J. Christie and C. Barry Hoffmaster," TheLinacre Quarterly: Vol. 53 : No. 4 , Article 15.Available at: http://epublications.marquette.edu/lnq/vol53/iss4/15BOOK REVIEWS Ethical Issues in Family Medicine by Ronald J. Christie and C. Barry Hoffmaster. Ox/iml Unil'l'rsily Press. Nell' York . 198(5, 190 PI'. Ethi('{1llsslil's in Fall/ill' Medicine was a difficult book to review. It is an important book because it attempts to deal with ethical issues in family practice. I am sympathetic to many of the ideas which emphasize the importance of family practice and the importance of understanding the need for a comprehensive knowledge of each patient. including that patient's relationship to the family unit and its concern. particularly about the individual as a person with a major emphasis on emotional factors . This provocative presentation of a unique theory on ethics in family practice by Christie (a family practitioner now deceased) and Hoffmaster (a member of the philosophy department) apparently rose out of their work together in the family practice program at Western Ontario University in London. Canada. The volume is provocative. in part. because it is unconventional. They find themselves dealing with the current dilemma of establishing a balance between patient autonomy and professional paternalism. They appropriately reject both as absolutes and attempt to arrive at some middle ground. Their answer seems to be to remove moral dilemmas from the area of decision-making (appropriate to a consideration of both autonomy and paternalism) and shift it into a moral grounds in which the family physician becomes virtually the II/oral guardian of both the individual and the family unit. They appropriately point out that ' the idea of total autonomy in the medical model is a fallacy because. even as a physician informs a patient about his condition. he is necessarily being formative and also conveying almost certainly some type of emotional support. A good physician. as physician. should be doing both. In the book. the authors give a series of almost too brief clinical vignettes on various topics. They then list the various options for each case report and then begin their ethical discussion. The methodology is appropriate and sometimes helpful but it is. at other times. difficult to relate the discussion back to the cases since they refer to them by case number. In general. they appear to recommend specific answers based on what seems to be the premise that their ultimate duty is to the patient. even if it violates the physician's own moral position (p. 143). As they attempted to distinguish between their assigned role as a "moral guardian" and being supportive of the patient as an individual. it seems that they have placed themselves in a situation which. when it becomes untenable as the patient desires otherwise. they abandon their own moral standards. This wold seem to require a mindset more peculiar to the legal profession than to the medical profession. "Where morality or religious consciousness is the source of disagreement. however. an appreciation of his own normal fallibility and commitment to the patient as a person argues strongly in favor ofa stance of , agreeing to disagree' in accepting the patient's decision. A family doctor should recognize that making a decision which tests one's moral convictions can be troubling for the patient and should support him through it. He can use the November, 1986 87 opport un ity to foster personal growth by having the patient reflect on the values in question a nd critically assess them. But ultimately. his commitment is to the patient. and that can enta il becoming a party to conduct that vio lates his own moral views ... When these differences manifest themselves in a medical setting. he can be forced to subordinate personal moral beliefs to the goal of helping patients with whatever problems they may be having." First of all is a danger in the approach that Christie and Hoffmaster present. in that. if th is becomes a standard of teaching (as it was. apparently. in their family practice program). they will first of all attempt to indoctrinate their patients and their families into their own moral belief. using the power whic h is unique to the physician. but a t the same time. be ready to comp romise their own moral principles when the patient c hooses to reject them. For instance. t heir approach would appear to justify active cooperation in abortion if the patient chooses that option . In my judgment. it would be more consistent if they suggested that the physicians make aware their own moral position. refuse to compromise those morals but. at the sa me time. not reject that patient as an individual. continuing to show him / her compassio n. understanding and continue to recognize the patien!"s individual worth even though disapproving of spec ifi c actions. One specific examp le in which the physician's own sta nd ard is one which appears to be imposed on the patient is given on pp. 79- 80. A diabetic American Indian woman has gangrene of a leg a nd is refusing amputation. The decision to try and influence her to have the amputat ion. even though somewhat paternalistic in approach in my judgment. is a reasonable and ethical medical judgment. The woman in the story attempts to solve her problem with traditional medicine and appears in danger of death. The decision to encourage her to have the amputation was made. however. in large extent in order to introduce some emotional stabi lit y into the li ves of two teenage grandchildren. This is an argume nt from utility a nd one could easily argue the other way that. to remove the grandmother from the home might have a lso brought about increased stability had the circumstances been somewhat different. This points out the danger again of medical decisions being happil y latent with mora l connotation (often inappropriately) for basic utilitarian reasons. a lthough it is true that. in fami ly practice as in any part of medicine, there are major ethical dilemmas which are becoming more prominent. However. in the majority of these situations (as in the case of this woman). sound medical judgment as the basis of decision-making is typically morally correct. Another example (pp. 75-76) argues, in my opinion. for aggressive intervention . In this example. a man with a chronic anxiety reaction has refused therapy. The physician rejected follow-up appointments but. when the man's wife went in to see the'same physician about a pregnancy, "the physician uses the wife's antenatal exarrinations to continue treatment of the man through her." They argue that this " broad er view of the moral role of the family doctor" is appropriate. This, in my judgment, is inappropriate rejection of the man's autonomy. The phys ician's role would be to recognize the husband's emotional problems as he deals with the woman's pregnancy and subsequently with the care of the child . However. to "treat" the man himself through other members of the family is inappropriate paterna li sm. Chris ti e and Hoffmaster have made a n important contribution to the field of ethics by bringing to our attention an area which has been neglected. Om concentration on intensive care problems. abortion and in vit ro fertilization has been o n fields which have primarily involved the medical specialist and subspecia list. There is no question that et hical considerations in family practice have not received the attention they should have. This is an important book because of its provocative approach. It has opened the doors, I trust, to further discussion and will clearly open our eyes in some areas. As viable as it is. it is not the last word. -Robert J. Barnet, M.D. Reno, Nevada 88 Linacre Quarterly 

[Book Review of] \u3cem\u3eEthical Issues in Family Medicine\u3c/em\u3e, by Ronald J. Christie and C. Barry Hoffmaster

https://epublications.marquette.edu/cgi/viewcontent.cgi?article=3655&amp;context=lnq

[Book Review of] \u3cem\u3eEthical Issues in Family Medicine\u3c/em\u3e, by Ronald J. Christie and C. Barry Hoffmaster

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